Basic Information
| Provider Information | |||||||||
| NPI: | 1336152529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITT | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 STUART ST | ||||||||
| Address2: | MACH ATTN: MCXL-PQ (CREDENTIALS) | ||||||||
| City: | FORT JACKSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292075720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037512618 | ||||||||
| FaxNumber: | 8037512689 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 STUART ST | ||||||||
| Address2: | MACH/CREDENTIALS | ||||||||
| City: | FORT JACKSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292075720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037512618 | ||||||||
| FaxNumber: | 8037512689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1070 | SC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.